It’s a question that seems almost rhetorical to most public health advocates. “Of course,” they say. “If we can, we should.”

This is the conventional wisdom, often presumed to have been settled long ago and to be effectively beyond question.

But historian Dr William Muraskin from the City University of New York has just published a provocative new book which asks whether mobilising the global health community in the fight against polio is the best use of scarce resources. It has raised plenty of eyebrows but also some valid questions about the future direction of immunisation and development policy.

The vaccine bonds initiative has been hailed by world leaders as “a catalytic success story and one that is constantly attracting new members”. An official G8 report from the May 2012 meeting at Camp David describes the IFFIm as part of a “game changing” effort for global immunisation.

Efforts to slash rates of preventable illnesses and to make a final push for the eradication of polio have built momentum in recent years, yet global financial instability threatens to derail progress in a number of areas.

Funding for these immunisation drives comes in part from wealthy philanthropists – many of whom have seen their wealth diminished by collapses of the value of shares and property in the Western world.

But it’s the contribution of governments that is facing most strain. Fiscal austerity in Europe and spending cuts in the US mean foreign aid budgets are under pressure, prompting some commentators to ask whether the ‘good times’ in global health are coming to an end.

Cost of credit downgrades

That’s the obvious, direct impact of the financial crisis on development aid. More subtle is the impact of decisions made by credit ratings agencies to downgrade the debt of European governments. Vaccine bonds have been a huge hit with the markets and have injected millions of euros into the global health effort but they have not been immune (pardon the pun) to the vagaries of financial markets.

The IFFIm was downgraded by Standard & Poor’s in January 2012. Having previously been AAA-rated (implying that it is the safest form of investment), it was reduced by one notch to AA+ with a warning that more downgrades could follow.

This is still a pretty ‘safe’ investment but it means that the IFFIm has to pay higher interest rates when it sells bonds, effectively making it more expensive to raise money. That translates into less money being available to spend on vaccine programmes.

Why the downgrade?

The IFFIm is supported by guarantees from the UK, France, Italy, Norway, Australia, Spain, The Netherlands, Sweden and South Africa. France guarantees one quarter of the IFFIm’s debt so when French government debt was downgraded in early January it was almost inevitable that the IFFIm would come under the spotlight.

The UK, the biggest supporter of the fund, is also on a ‘negative outlook’ suggesting a downgrade could be announced if the economic situation worsens, while Italy and Spain have also been repeatedly downgraded over the past year. In short, if the people guaranteeing your debt are seen as less creditworthy than in the past, you will see your creditworthiness fall too.

When discussing the impact of the financial crisis on health services in European countries we might also spare a thought for those in the developing world who depend for their survival on foreign aid and investment in vaccine bonds.

Who knows, maybe the true cost of failure to tackle the Eurozone will be defeat in the global war on polio. The disease is endemic in just a handful of countries and there have been no new cases in Europe for 10 years. Let’s hope progress is not about to be thrown off course.

This is an abridged version of an article originally posted on the Vaccines Today blog

Bertie Ahern and Padraig Flynn were removed from the list of the great and the good which includes Mary Robinson, Peter Sutherland, Pat Cox, Brian Cowen, Charlie McCreevy and – a new addition – Enda Kenny.

Ahern, who served as Ireland’s Taoiseach (Prime Minister) from 1997 to 2008, was humiliated by the Mahon Report, although the judge did not find hard evidence of corrupt payments. The report says that Ahern gave “untrue evidence” and that he “failed to truthfully account for IR£165,214.25″ which passed through his accounts.

IIEA did the right thing the wrong way

When the Mahon report was published in March I sent questions to the IIEA publically via Twitter asking if the would be removing Ahern and Flynn from their Comité d’Honneur in the wake of the Mahon findings. Even when the two disgraced politicians were kicked out of their own party, there was no word from the IIEA.

Then, without any publicity, the names of Ahern and Flynn disappeared from the IIEA website. I asked the IIEA how this decision came about, giving them ample time to reply, but no answer to those questions was received. (I was informed, 10 days after my emailed query, that Michael D. Higgins, the newly-installed Irish President, would be the organisation’s new patron.)

It’s odd. The IIEA is an esteemed organisation and has done the right thing – so why the silence?

This week, as EU leaders gather in Brussels, the IIEA is hosting an event in Dublin to discuss ways out of the crisis. Speakers include Patrick Honohan (ECB board member and governor of the Irish Central Bank), Alain Lamassoure MEP (Chair of the European Parliament’s budget committee), John Bruton (former Taoiseach and EU Ambassador to the US), Donal Donovan (former Deputy Director of the IMF), Josef Janning (Director of Studies at the European Policy Centre) and Pat Cox (former President of the European Parliament).

How did such a well-connected organisation manage to react so slowly to the Mahon Report and why did it feel it necessary to preserve the honour of two politicians who had, by their own actions, squandered whatever respect they once commanded? Why spare them the humiliation of a public statement condemning their actions and stripping them of this honorary role?

Perhaps it is the very fact of the IIEA’s connectedness that saw Ahern and Mahon given such a gentle boot. At a time when the public may be tempted to think that the elite is living by a separate code and protecting its life-members from hard landings, this was an opportunity missed.

The farcical tale of Mr Rasi’s own appointment offers some insight into the behind-the-scenes chaos at Europe’s medicines watchdog.

Back in 2010, Rasi’s predecessor, Thomas Lonngren was preparing to step down after two five-year stints as Executive Director. The post was advertised but had to be withdrawn due to supposed translation errors. A second ad was published only for the European Commission to dispute the pay grade on offer, stalling the recruitment process for several months while Brussels pushed to downgrade the job.

After many months of wrangling, the Commission eventually relented, allowing the EMA board (headed up by Pat O’Mahony, Chief Executive of the Irish Medical Board) to offer a highly attractive package to interested candidates.

Still, this deal came too late. Mr Lonngren departed on schedule in December 2010 leaving a vacuum at the head of the medicines regulator for the bones of a year. Andreas Pott, the Agency’s head of administration, served as Acting Executive Director until Mr Rasi took over before Christmas 2011.

Pott’s luck

Mr Pott’s first headache was to deal with reports that Mr Lonngren was providing advisory services to pharmaceutical companies – the kind of firms who might be expected to seek EMA approval for medicines.

However, it ultimately enforced ‘limitations’ on his activities, preventing him from interacting with the Agency for two years, and introduced a raft of new guidelines on conflicts of interests for its staff, experts and board members. The horse, of course, had bolted but it’s better late than never.

The Financial Times reported that Mr O’Mahony had himself been seen as a frontrunner to replace Lonngren but failed to muster enough support when it came to the crunch last summer, opening the way for Mr Rasi (a former Director-General of the Italian Medicines Agency). Mr O’Mahony had been elected EMA chairman for three-year terms in 2007 and 2010 but opted to step down in 2011 shortly after the board voted to appoint Mr Rasi.

‘Axe the expert?’

Before Mr Rasi could take up his position, there was plenty more incoming fire for the seat-warming Mr Pott to fend off. His first opponent was French MEP Gérard Bapt who wrote to the EU Health Commissioner John Dalli suggesting that an EMA expert be fired. A bitter row ensued.

Mr Bapt’s gripe was with Dr Xavier Kurz, a Belgian scientist and EMA advisor. Back in 1994 when Dr Kurz worked at a university and provided part-time advice to the Belgian authorities, he wrote a report on the safety of an appetite suppressant. The drug would later be taken off the market in due to concerns over cardiac side effects. According to the French MEP, the report by Kurz “minimised and contested” the risks associated with the medication.

Pott was having none of it. He wrote to Mr Bapt defending the 1994 report which he said had added to the scientific understanding of the class of medicines in question.

“I would like to reiterate my absolute confidence in Dr Kurz’s scientific and personal integrity,” he added, refusing point-blank to censure the EMA expert.

The EMA’s relationship with the European Parliament, at best be described as strained, has sunk to a new low in recent times. The Parliament’s Budget Control Committee has also lashed out at the Agency’s supposed transparency deficit when it comes to recruiting staff and it has criticised the way it manages public procurement contracts.

In a fit of pique, MEPs delayed signing off on the EMA’s budget, citing the lack of “proper guarantee of the independence of experts hired to carry out scientific evaluations of human medicines”. A thinly-veiled reference to the Kurz affair perhaps?

Transparency plans

The problems didn’t stop there. With the Agency launching a five-year transparency plan, it was discouraging to read an exchange of terse letters between Mr Pott and the Nordic Cochrane Centre in Denmark. To be fair, the Danes started it.

The Cochrane group wrote a damning critique the BMJ accusing the medicines regulator of refusing to publish clinical data which doctors could use to make informed decisions before writing prescriptions.

The Danes and others had been trying, through various routes including the EU Ombudsman, to force the EMA to release more clinical information. The Agency had been deeply reluctant to do so given the commercially sensitive nature of the data but, Mr Pott noted in a rebuttal published by the BMJ, the regulator has launched a new clinical trials register and is sharing as much information as it reasonably can.

Shock departure

With the dust settling on a series of public rows, there was some relief when Mr Rasi arrived, new broom in hand. But no sooner was he installed than another crisis erupted.

This has little to do with the Mr Rasi or his predecessors but rather was the latest twist in a complex regulatory scandal gripping the French medical establishment. Following serious criticism by politicians and the media in France, the French medicines regulator has been undergoing a major restructuring which saw Dr Adabie’s contract terminated.

Dr Adabie’s work at the EMA was unpaid (he drew his salary from the French authorities) and his attempt to secure direct payment from the European agency in light of his departure from the regulator in France was rebuffed. So he cleared his desk.

New broom

To this string of calamities you can add the usual criticism of medicines regulators: it takes an age to secure approval for new medicines, leaving patients waiting too long for the latest treatments.

The answer to much of this criticism is more transparency. More transparency helps explain why decisions take so long; how decisions are taken and by whom; how money is spent and how contracts are awarded.

Despite its considerable influence over Europeans’ health, the regulator has often specialised in keeping a low profile. Its technical public statements frequently translate as “Don’t look over here – honestly, we’re really boring.”

All of that, says Mr Rasi, is soon to change. Greater transparency is promised on clinical data, on funding for patient groups and on the role of experts. The EMA has begun publishing meeting agendas and more detailed minutes.

Some of this work had been initiated long before Mr Rasi became Executive Director, having been set in train by previous directors and the EMA board when it was led by Pat O’Mahony.

A fundamental shift in organisational ethos is what is required. With a new man at the helm, potentially for the next decade, the time for renewal is nigh. Failure to change will undermine public confidence in the safety of medicines at a time when faith in authorities is under pressure.

[This post is based on a forthcoming feature in Irish Medical News]

The European Medicines Agency

What does it do?

The European Medicines Agency (EMA) is a London-based EU body which assesses medicines to make sure they work and are safe.

Pharmaceutical companies can apply for permission to sell human medicines and veterinary products across Europe, although negotiating prices is chiefly a matter for national authorities and insurers.

The Agency also monitors the safety of medicines sold in Europe through an extensive pharmacovigilance network and from time to time withdraws or updates drug marketing licenses on foot of new evidence of adverse reactions.

It has six scientific committees and a network of over 4,500 experts who help to assess medicines.

What does it not do?

The EMA does not evaluate all medicines used in the Europe. Companies can apply to national authorities to sell their medicines in an individual EU member state rather than pursue a single European marketing authorisation from the EMA.

The EMA does not conduct its own laboratory research or clinical trials – that task falls to those applying for marketing licenses. It does not set prices or judge what medicines should be reimbursed by governments. Nor does it decide what kinds of clinical research should be given ethical approval.

At present, the Agency does not regulate medical devices – such as pacemakers, hip replacements or breast implants. However, innovations such as drug-eluting stents continue to blur the line between medicines and devices.

EU leaders seem to have just discovered the EIB but the truth is the bank has grown increasingly active since the crisis broke

In the sleepy Luxembourg headquarters of the European Investment Bank they are unsure how to handle their 15 minutes of fame.

Suddenly everyone from François Hollande and Angela Merkel to David Cameron and Enda Kenny are looking to the EIB to drive growth across the moribund bloc. While it must be nice to be noticed, the investment bank has in fact been hyperactive since the crisis broke in 2008.

In the immediate aftermath of the Lehman collapse, the EIB unveiled a €30 billion programme of loans and guarantees for small businesses which was distributed through commercial banks.

The EIB spread €13 billion around Europe for small companies last year. Add to that the €10 billion it invested in the ‘knowledge triangle’ of education, innovation and research and it becomes clear that tapping the EIB is not a new idea.

It began ramping up its activities long before Monsieur Hollande was elected. Last year it disbursed €60 billion to the “real economy” – its highest ever output – taking its outstanding loans to €395 billion.

Yes, the bank’s AAA rating and its ability to leverage relatively meagre capital into a substantial investment fund has made it flavour of the month but it has been part of the EU’s crisis response from the start.

In my defence, I haven’t used it for five years and I now forget the password.

However, for dozens of our esteemed Members of the European Parliament (MEPs), wandering alone in the social media wilderness we call MySpace is a regular pursuit.

According to the EU Digital Pulse 2012 report, 3% of the 102 MEPs surveyed by ComRes say that they frequently – that’s ‘daily or weekly’, ladies and gentlemen – log on to MySpace. And they say politicians are losing touch with youth vote…

WikiPolitics

I’m being a bit mean-spirited by plucking that particular little nugget from the wealth of data unveiled by the ComRes survey. MEPs are actually quite a social bunch.

A healthy majority of MEPs use Facebook, YouTube and Wikipedia on a regular basis. Compare that with the 39% of ‘Brussels influencers’ who frequently use Facebook.

Perhaps surprisingly, MEPs have been relatively slow to embrace the power of Twitter compared to some of their national political counterparts and their usage of LinkedIn seems low (given that their contracts are up for public renewal every five years).

Questions for further study

Like all good research, the study provides answers to some key questions but raises a crop of fresh issues too. At the launch of the study at a European Commission building in Brussels, a common thread ran through the questions from the audience: engagement.

Yes, just about everyone in the Brussels bubble is hooked on Wikipedia but are they just using it for research or do they view it as a collaborative social tool?

Do MEPs use Facebook as a place to engage with constituents or is it just an extra broadcast channel?

And when we see European Commissioners firing out 20 tweets a day, are they (a) doing it themselves (b) telling their team what to tweet or (c) entire oblivious to what their tweet machine is generating?

Those are questions for another day but this study already tells us a great deal about how Brussels is using social media. And, as Andrew Hawkins of ComRes said, it opens up a world of opportunities for those looking to engage on EU issues.

New tools, new thinking

ZN’s Phil Weiss followed up with some tips for organisations looking to make the most of social media tools, including the need to break down internal silos and begin a wholesale mindset shift that focuses on where you want to go rather than obsessing about how you get there.

It’s advice that EU institutions would do well to heed but there are plenty of great examples of social media use from within the Brussels bubble – typically led by initiative-taking individuals willing to abandon old ways of thinking.

Take Ian Andersen of DG Interpretation. He is using Facebook to solve a chronic staffing shortage among the ranks of EU interpreters as hundreds of experienced staff prepare for retirement. [Check out ‘Interpreting for Europe’ on Facebook]

He chose Facebook simply because that’s where young people are to be found. It’s an ideal medium for answering questions, giving careers advice and launching recruitment drives for very specific skill sets – how else would you find a batch of 25-year-olds fluent in Lithuanian, Latvian and German, who also have degrees in interpreting?

Demographics

Dig into the ComRes study and you find that younger MEPs are much more prolific on social media channels than older MEPs. No shock there.

But there are still plenty of older politicians who are active online. Indeed, Thomas Myrup Kristensen of Facebook Nordic, who was one of the panellists discussing the report at the launch, noted that the older demographic is an area of rapid growth on Facebook.

They are ‘liking’ baby pictures, keeping up with emigrant offspring, and joining local community action groups. Maybe, just maybe, they could eventually engage in European political issues.

The acid test from an EU perspective will be the 2014 European Parliament elections. Will MEPs step up their online social networking in a bid to engage voters? Could they even use online advertising to target very specific sub-sections of the electorate? Think of the US obsession with the ‘Soccer Mom’ demographic during their 1996 Presidential election and imagine having Google AdWords and Facebook advertising at your disposal.

All of which brings me back to the big question: Could this election come to be remembered as ‘The MySpace Election’?

Doctors from across Europe are gathering in Athens on Saturday for an emergency meeting amid fears that the Greek health system is going into meltdown.

The hastily-arranged medical summit, called by the Medical Association of Athens, is due to discuss plans for a new European Medical Network through which doctors could support the ailing health service in Greece.

This news was broadly welcomed by political leaders and financial markets but doctors say there is little reason to celebrate.

The Medical Association of Athens has had to set up makeshift clinics to care for the growing number of Greeks who can no longer afford health insurance.

The Assocation’s President, Dr George Patoulis, said “drastic legal interventions” have been introduced and he called on the medical profession across Europe to support Greek patients.

“During these difficult days, solidarity on behalf of the European medical community is more than ever of great significance,” he wrote in a letter to the President’s of medical bodies across Europe. (I have a copy but cannot link.)

“Your experience, as a result of evidence based medicine and health policy patterns in your countries, is important for us in order to confront the new healthcare frame.”

The meeting is due to debate strategies for shielding health protection initiatives at a time of deep cutbacks. It will also look at best practice in drug and prescription policies, and the liberalisation of the medical profession.

Dr Patoulis said Greece is offering licenses to “non-doctor entrepreneurs” to run primary care centres as part of its agreement with the EU and IMF to introduce competition to the professions. A similar push to open up the ‘protected professions’ can be found in fine print of the bailout deals agreed by Ireland and Portugal. Italy is also attempting to liberalise its pharmacy sector, despite considerable resistance from pharmacists.

(According to the invitation, the Medical Association of Athens was offering to pay for accommodation and a cultural visit to the Acropolis museum of Athens.)

Three years after it was proposed the EU Information to Patients Directive is in limbo

European health ministers have poured cold water on a long-standing EU proposal to allow pharmaceutical companies to provide information on medicines directly to patients.

Ministers say the Information to Patients Directive could increase red tape for government agencies and companies if they are required to vet information which is designed for public consumption.

EU law currently prohibits companies from advertising to consumers but, as part of the 2008 “pharmaceutical package” of new medicines legislation, the European Commission proposed allowing some factual information about medicinal products to be published in newspapers and magazines.

Consumer groups were sceptical of the original plan, fearing it would open the door to the kind of hard-sell drug advertising commonly seen on television in the United States.

MEPs were equally uneasy about some aspects of the Commission’s proposal and insisted that safeguards be put in place to ensure any information shared with the public is objective rather than repackaged marketing material.

The saga has been a case study in how the slow-moving machinery of EU legislation works: the Commission proposes a new law, MEPs amend it in several parliamentary committees before voting on it, and then it falls to the European Council where health ministers decide whether and how to implement it.

Inter-institutional power play

The law now under consideration bears little resemblance to the draft published in 2008. The directive has been in the works for so long that it has seen the election of a new European Parliament in 2009 and the appointment of a new European Commission in 2010.

Perhaps even more significantly, the directive was originally drafted by the Commission’s ‘Enterprise & Industry’ directorate which was then responsible for pharmaceuticals and was widely seen as having a pro-business agenda.

However, in 2010, responsibility for medicines was handed to John Dalli, the new EU Commissioner for Health and Consumers – himself a former Maltese health minister. This shifted the debate towards consumer protection and patient empowerment.

Companies say they want to share fact-based information about products in print and on the internet given the enormous amounts of data and opinion about medicines and diseases already accessible online, some of which is of dubious quality.

Consumer and patient groups argued that any information provided by industry would have to be vetted by independent experts before being put in the public domain and this was one of the aspects of the directive presented to health ministers.

It seems the directive is going nowhere fast as national governments say the need to cut red tape and contain costs for businesses trumps demands for high-quality information on medicines. Paola Testori Coggi, director general of the Commission’s health and consumers arm, said the delay is regrettable but she sees little prospect of an immediate break in the deadlock.

All pain, no gain

Without attempting to judge whether health ministers, MEPs or various arms of the Commission are ‘right’ in their approach to getting this law through, it’s safe to conclude that a huge amount of time and money has been wasted on this mangled legislation – and citizens are none the wiser and no better off.

The reality of budget cutbacks is hitting frontline health services across Europe as governments close wards and patients beg for medicines

At the turn of the year, the Czech Republic sent a platoon of army doctors to help neighbouring Slovakia keep its hospitals open after a mass walk-out of 1,600 medical staff.

A state of emergency was declared as the government scrambled to find a way of solving a chronic medical manpower crisis prompted by an exodus of young doctors. Medical graduates are shunning the €430-a-month contract on offer in the pared-down Slovak health service, in favour of jobs in Germany paying starting salaries of €1,890 per month.

Welcome to Austerity Europe. This is barely the tip of the iceberg. Doctors in Romania and Hungary are threatening to copy the action of their Slovak colleagues in protest against yet another round of pay cuts introduced in an effort to rein in budget deficits.

Patients took to the streets in Romania this month to protest against the government’s new Health Bill which will institute a fresh round of cuts. Violent scuffles followed, with some protesters hurling Molotov cocktails at riot police. Observers say it is the worst public order disruption since the Romanian people turfed out Nicoale Ceauşescu in 1989.

Plus ça change

In Bulgaria, just 4% of the 2012 budget has been earmarked for health – a small slice of a shrinking pie. Staff have seen salaries fall and workloads rise. They’ve never heard of Croke Park in Sofia.

Lithuania too made swingeing cuts to its public sector, slashing spending by 30% early in the crisis. The result was hardship across education and health services, although the Lithuanians are slowly finding their feet again having also devalued their currency.

The picture is less positive in Hungary. The IMF was invited into Budapest in 2008, but relations have been strained since the 2010 election returned a populist party which blames foreign creditors for their home-grown woes. Hungary is currently trying to negotiate an additional bailout programme with the IMF and EU but promising its people that it will not accept further austerity as a precondition for cheap money. Good luck with that.

Non-eurozone countries have taken plenty of pain but are not in the glare of the media spotlight because, frankly, it doesn’t affect the rest of us that much. Some Europeans are more equal than others, it seems.

Indeed, surveys in several former Eastern bloc states show the grinding poverty of EU membership is not going down well – there is now rising nostalgia for the grinding poverty of the communist era. Plus ça change, plus c’est la même chose.

Austeritis maximus

Economists are divided on whether austerity is the solution to the crisis. To some, cutbacks are the tough medicine Europeans must swallow if they are to live within their means. To others, austerity is poison and Europe has been administered a lethal dose.

For the Greeks, where austerity has been taken to the extreme, the choices are stark: continue to slash health, education and welfare spending while staying in the euro. Or leave the euro and continue to slash health education and welfare spending. (Sound familiar?)

Greece takes plenty of flak for its lacklustre efforts to collect taxes and failure to take on vested interests but the evidence of its health services austerity push is plain.

The drug supply chain has collapsed, leaving patients pleading with doctors and pharmacists to source routine medicines like aspirin and beta-blockers. The Panhellenic Associaiton of Pharmacists says half of the country’s 12,000 pharmacies are reporting shortages in frequently-used medicines.

Crisis hits medicines supply

The reasons for the medicines crisis are complex but boil down to the government not having the cash to pay its bills. Earlier this year several large drug companies accepted deeply discounted government bonds in lieu of payment owed by public hospitals.

Why? They had waited two years for payment and wanted to cut their losses. Some have now left the country altogether while others insist on cash-on-delivery rather than issuing invoices for which they know they will not be paid.

Meanwhile, the government has not been reimbursing pharmacists who dispense medicines on drug payments schemes. Around €330 billion is owed to retail pharmacists since April of last year, causing a chronic cash-flow crisis.

As a result, supplies are running dangerously low, because wholesalers are no longer willing to provide medicines to retailers on credit, for fear of being left with more bad debts.

The government has also introduced price controls for medicines, meaning they will not pay more than a unilaterally agreed fee per dose. Naturally, the price they set is significantly down on last year, which was down on the year before. Some wholesalers have responded by taking their stock and exporting it to markets which are still functioning.

At the end of the broken supply chain are patients. Where drugs are available, pharmacists are typically asking for cash payment, advising patients to seek reimbursement from the state insurance companies – a task previously undertaken by pharmacists. Many of those who cannot pay up front must go without.

Unseen victims

Meanwhile, as bad as things are across Europe, spare a thought for the truly forgotten victims of European austerity: developing countries.

With all this talk of ratings agencies and sovereign bonds, it would be easy to think that governments were the only people seeking to sell IOUs on the international credit markets.

They are not. The International Finance Facility for Immunisation raises money to invest in vaccines for the world’s poorest countries. Because it is dependent on countries like France as a guarantor of its funds, it too has felt the wrath of a ratings agency downgrade.

This makes it more expensive for it to borrow money which in turn translates as fewer children getting vaccinated in polio-ridden Pakistani slums. That might sound remote to us but the 2010 polio outbreak in Eastern Europe was traced back to Indian villages. Infectious diseases mastered globalisation long before we did.

It’s a similar story for independent aid organisations in need of cash to rebuild housing in Haiti or fund clean-water projects in Uganda.

Add to that the fact that most ‘rich’ countries seeking to balance their budgets have cut foreign aid spending, and debates on whether Irish children’s allowance should be cut by €10 a month become embarrassing.

There is no simple way to fix all of this. What was can hope for is a better appreciation of the hierarchy of priorities. Should Greece be closing hospitals while buying fighter jets? Should Irish civil servants taking early retirement with gold-plated pensions be protected while children wait more than a year for surgery? Will foreign aid budgets suffer so Europe can afford to prop up out-dated industries?

Chronic drug shortages in Greece have left thousands of patients without medicines and paralysed the drug supply chain.

The impact of the ongoing financial crisis in Europe is having a deep impact on patients – and that’s before the possible return of the Drachma which could at least double the relative cost of imported medicines.

The Panhellenic Association of Pharmacists (PAP) says almost half of the country’s 12,000 pharmacies have reported shortages of the most-used medicines.

Drug companies and wholesalers are either out of stock or will not supply medicines for which they will not be reimbursed. Some suppliers have been left without payment for up to two years and have now run out of patience.

As a result, the PAP says their members spend hours on the phone pleading with suppliers and colleagues to provide medicines like aspirin, albuterol and beta-blockers. In some cases, where patients are in dire need, pharmacists’ have resorted to paying for drugs themselves.

Price controls

In an effort to radically cut costs, the Greek government has introduced price controls meaning wholesalers must charge lower prices than last year. As a result, some suppliers are selling their products outside the country where higher prices are still on offer. In addition, pharmacists complain that the government’s fiscal problems have led to lengthy delays in payments to pharmacists and drug manufacturers which have bred cash-flow problems for retailers.

Public health insurers owe pharmacists around €330 million for drugs bought since April, according to Dimitris Karageorgiou, vice-chairman of the PAP, who acknowledged that some pharmacists are demanding upfront patients from patients who must then chase their insurance companies for reimbursement.

The entire supply chain is close to collapse now that some wholesalers are no longer willing to provide pharmacists with extended credit terms for fear of not being paid.

Last year, large drug companies were forced to accept Greek bonds in lieu of cash owed by public hospitals because the government had run out of money. Some firms cut their losses and left the country while others now insist upon payment on delivery rather than issuing invoices.

At the end of the line are patients, particular those with chronic illnesses, who are often unable to pay for medicines on an ongoing basis, yet know that the prospect of an economic upturn is unlikely in the foreseeable future.